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Pediatric Patient Safety Learning Laboratory to Reengineer Continuous Physiologic Monitoring Systems

Principal Investigator:Christopher Bonafide, M.D., M.S.C.E., Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA
AHRQ Grant No.: HS26620
Project Period: 09/30/18-07/31/23
Description: This lab’s goal was to reengineer physiologic monitoring of children to make alarms more informative.

The specific aims were to1: 

  • Reengineer the system of monitoring hospitalized children in acute care wards, focusing on reducing noninformative alarms and accelerating nurse responses to critical events.
  • Reengineer the system of monitoring infants with bronchopulmonary dysplasia at home, focusing on reducing noninformative hypoxemia alarms and improving clinicians’ access to usable longitudinal pulse oximetry data to inform supplemental oxygen treatment.

This PSLL comprised a diverse group of physicians, nurses, scientists, engineers, designers, and support staff. They followed a planned five-step phased approach (i.e., problem analysis, design, development, implementation, and evaluation) to understand physiologic monitoring problems and iteratively test solutions in the home and hospital settings.1

For the hospital setting, the lab reconfigured and standardized alarm limit defaults across all medical-surgical units at CHOP. In addition, they updated policies and provider order entry, educated providers, and integrated new alarm system technology (i.e., middleware and smartphones to pass alarm messages to nurses via mobile phones). 

These interventions resulted in a 21 percent reduction in alarm notifications (27.4 to 21.6 per occupied bed day) and a 59 percent improvement in response to alarms. In addition, the lab designed an alarm manager to actively filter nonactionable alarms by suppressing them before they reached the bedside nurse. They also amplified actionable, critical alarms by directly calling the nurse when actionable alarms occurred.2,3

For the home setting, the lab provided clinical decision support in a letter detailing the required elements of home oximeter ordering, along with more liberal age-specific default alarm limits. This information resulted in a significant decrease in the median low pulse oximetry limit and a significant increase in home oximetry order completeness.1,4,5 

Other interventions include the following1,6: 

  • National guidance for pediatric monitoring, called Best Evidence for Effective Pediatric monitoring (BEEP), was developed after researchers found the only existing guidelines focused on avoiding continuous pulse oximetry for acute viral bronchiolitis. 
  • The CHOP Center for Healthcare Quality and Analytics Patient Monitoring Taskforce was created to institute a sustainable mechanism within the hospital to continue solving pediatric patient safety problems after the grant ended. 
  • Clinical decision support was integrated into the electronic health record (EHR) to mitigate misalignment of guidelines with practice.
  • Optimal notification tones were created for pulse oximetry alarms to improve nurses’ identification of them.
  • In situ simulation was developed to evaluate nurses’ ability to detect and respond to simulated life-threatening critically low pulse oximetry (<70%) alarms.

To date, this PSLL’s work has resulted in two national awards and at least 16 peer-reviewed journal publications that have been cited 115 times in other publications.

Awards

  • The 2021 AAMI & Becton Dickinson’s Patient Safety Award, which recognizes outstanding achievements by healthcare professionals who have made a significant advancement toward the improvement of patient safety.
  • The Biomedical Instrumentation & Technology Journal Editorial Board’s Best Article of 2020 for its paper, Protocol for a new method to measure physiologic monitor alarm responsiveness.

Publications

2024

  • Ruppel H, et al. A systems engineering approach to improving alarm management in pediatric medical-surgical units. J Hosp Med 2024 Oct 17.

2023

2022

2021

2020

References

  1. Bonafide C. Final Report: Pediatric Patient Safety Learning Laboratory To Re-Engineer Continuous Physiologic Monitoring Systems. Philadelphia, PA: Children's Hospital of Philadelphia; 2023. pp. 1-18.
  2. Rasooly IR, et al. Physiologic monitor alarm burden and nurses’ subjective workload in a children’s hospital. Hosp Pediatr 2021 Jul;11(7):703-710.
  3. Rasooly IR, Bonafide CP. Making the case for limited physiologic monitoring in a data-hungry world. Pediatrics 2020;146(2):e2020003756.
  4. Craig S, et al. Characteristics of emergency room and hospital encounters resulting from consumer home monitors. Hosp Pediatr 2022;12(7):e239-e244.
  5. Ferro DF, et al. Parental insights into improving home pulse oximetry monitoring in infants. Pediatr Qual Saf 2022 Mar-Apr;7(2):e538.
  6. McLoone M, et al. Observing sources of system resilience using in situ alarm simulations. J Hosp Med 2023;18(11):994-998.
Page last reviewed January 2025
Page originally created January 2025

Internet Citation: Pediatric Patient Safety Learning Laboratory to Reengineer Continuous Physiologic Monitoring Systems. Content last reviewed January 2025. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/resources/learning-lab/physiologic-monitoring-long-desc.html

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